MEDICARE: SHANORVER WILLIAMS LMT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	MT013191	GA

General Provider Information

NPI Number	:	1548855067
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANORVER WILLIAMS LMT

Provider Business Mailing Address
First Line	:	2240 KRYSTLE WAY
Second Line	:
City	:	CUMMING
State	:	GA
Zip	:	30041-7291
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3133 MAPLE DR NE STE 120
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30305-2509
Country	:	US
Telephone Number	:	404-220-7770
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/05/2021
Last Update Date	:	03/05/2021

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